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concepts of nursing
Focused Assessments
| Question | Answer |
|---|---|
| In which order would the nurse perform an assessment of the integumentary system. | Review the patient’s medical records for preexisting issues with skin, hair, or nails. Interview the patient to complete the general survey, health history, and review of systems. Complete physical examination of the skin, hair, and nails. |
| Which components would the nurse assess during palpation of the skin? | Swelling Skin Texture Skin temperature |
| When the nurse identifies clubbing of a patient’s nails, which type of medical condition would the nurse suspect as the cause? | Cardiac |
| Which part of the eye would the nurse palpate gently to assess for nodules or pain? | eyelid |
| In which order would the nurse perform an assessment of the integumentary system. | sinuses |
| When examining the head and its associated structures, which unexpected findings would the nurse document? | Lumps Edema Lesions Discoloration |
| Which techniques would the nurse utilize to auscultate the patient’s chest during the respiratory assessment? | Listen for a full respiratory cycle. Use a systematic pattern. Listen for unexpected sounds. |
| Which aspects does the nurse assess while palpating the chest during the respiratory system assessment? | masses Skin moisture |
| Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment? | Depth of respirations |
| Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems? | Respiratory |
| Which actions would the nurse implement during auscultation of the cardiovascular system? | Assess rate and rhythm use both sides of stethoscope |
| Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities? | Peripheral perfusion |
| Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview? | Review of health records |
| Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination? | Masses Crepitus Tenderness |
| Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider? | pain lesions abnormal posture and gait |
| Which assessment technique would the nurse use during the neurologic assessment? | Inspection |
| Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body? | Sensory nerve |
| Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes? | Cranial nerve |
| Which assessment techniques would the nurse use during the abdominal assessment? | Palpation Inspection auscultation |
| The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems? | urinary digestive |
| Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope? | Bowel sounds |
| Which findings would the nurse recognize as abnormal during assessment of the male genitalia? | rashes lesions masses discharge |
| Which technique would the nurse use to palpate the breast tissue? | Two to three fingers |
| During the breast and genital examination, which findings would the nurse document and report to the health care provider? | lesions on genitalia presence of hemorrhoids unusual odor or discharge excoriation of the breast tissue |
Created by:
colby.caswell